This study is underpinned by Kolb’s Experiential Learning Theory, which provides a theoretical lens for understanding how students engage with simulation-based learning. Kolb’s theory conceptualises learning as a dynamic process that integrates experience, reflection, understanding and action (Shanthi & Malathi 2024). Simulation aligns with this theory by offering learners a controlled environment to experience clinical scenarios, reflect on performance, integrate theoretical understanding, and apply this in future situations.

Kolb’s Experiential Learning Theory was used to frame how students engage with simulation as an experiential process. Both SPs and HFMs support experiential learning, although they may emphasise different aspects of engagement, interaction and skill application. By comparing these two modalities, the study explores how each contributes to different stages of learning for early-year EMC students.

This study employed a quantitative comparative design, supplemented with qualitative data from open-ended responses. This mixed-methods approach was selected to provide both measurable outcomes and deeper insights into student perceptions. The design enabled comparison of satisfaction levels across two simulation modalities (SPs and HFMs) within the same clinical scenario.

Data collection took place in a university-based simulation laboratory in South Africa. This space is equipped with both high-fidelity simulation tools (e.g. Sim-Man 3G) and environments suitable for SP interactions.

No formal sample size calculation was undertaken, as the study was intentionally designed as a pilot. The sample consisted of all eligible and consenting first-year EMC students to explore feasibility and preliminary trends rather than achieve statistical power. First-year students were included to explore early perceptions of simulation modalities before extensive clinical or simulation exposure, which aligned with the pilot design of the study. At the time of data collection, the study population consisted of 38 first-year students who were enrolled in the EMC I theory and practical module (N = 38). A convenience sample consisted of 15 students who freely participated in the study (n = 15). All participants were above the age of 18 years and had received prior orientation to the simulation environment. While the small sample size limits generalisability, it remains valuable for exploratory and pilot purposes.

Participants completed the same simulation scenario twice, once using an SP and once using an HFM. The scenario involved the diagnosis and stabilisation of a tibia-fibula fracture following a pedestrian-vehicle accident. This case was chosen for its feasibility, clinical relevance and reproducibility across both simulation modalities. All participants completed the simulation scenarios using SP first, followed by HFM. Randomisation of simulation modality order was not undertaken because of logistical constraints.

The scenario included a standard pre-brief, consistent instructions, and access to identical simulation equipment in both sessions. Students were evaluated individually, without team interaction. No formal debriefing was conducted in this study. This was an intentional methodological decision aimed at capturing students’ immediate perceptions of the simulation modality itself, rather than reflections influenced by facilitator-led discussion or peer feedback.

A revised version of the Satisfaction Scale for High-Fidelity Clinical Simulation (SSHF) was used in this study (Jiménez-Álvarez et al. 2024). This 28-item Likert-type questionnaire measures eight domains, including simulation utility, case realism, self-confidence, theory-practice integration and perceived learning. Domain 3, focused on debriefing and team communication, was removed as the study focused only on individual performance without debriefing. Two open-ended questions were added:

The questionnaire was completed electronically following the simulation sessions, and responses were submitted anonymously with no identifying information collected.

Quantitative data were analysed using Microsoft Excel (Microsoft Corporation 2021).

Descriptive statistics (mean and standard deviation) were used to assess scores across domains and modalities. Open-ended qualitative responses were analysed thematically to identify common patterns.

The SSHF tool used had been previously validated (Alconero-Camarero et al. 2016). The 28-item SSHF questionnaire was analysed across seven domains. The five-point Likert-scale responses were collapsed into three categories to enhance interpretability, given the small sample size. These categories comprised disagreement (strongly disagree and disagree), neutral (indifferent) and agreement (agree and strongly agree). Likert-scale data were treated as ordinal data. Inferential statistical testing (such as the Wilcoxon signed-rank test) was not undertaken given the exploratory nature of the pilot study and limited sample size; such analyses are planned for future, larger-scale studies.

Open-ended qualitative responses were analysed thematically to identify common patterns.

Coding was done manually using an inductive thematic approach. No qualitative data analysis software was used given the small volume of qualitative data. Responses were read repeatedly, coded, and grouped into themes based on recurring patterns in the data. Initial coding was followed by categorisation into major themes such as realism, stress, communication and procedural confidence. Data saturation was not sought, as the qualitative component was exploratory and intended to supplement the quantitative findings in this pilot study. Qualitative findings were used to provide contextual depth to the quantitative results rather than to develop a theory.

Ethical approval was granted by the Faculty of Health Sciences Undergraduate Research Ethics Committee (REC-112-2022). Institutional and departmental permissions were obtained. Participation was voluntary, anonymity was ensured, and participants were informed of their right to withdraw from the study at any time. Written consent was given if participants wanted to participate in the study. Written informed consent was obtained from all individual participants involved in the study. Anonymity was ensured by collecting no identifying information, and questionnaire responses could not be linked to individual participants. Ethical approval was obtained through institutional processes, and all data collection adhered to principles of confidentiality and participant safety.

The overall mean satisfaction score for the SPs was 121.8 (s.d. = 11.52), and for the HFMs, it was 114.3 (s.d. = 12.5). Students reported high satisfaction with both modalities, with SPs scoring higher overall.

Table 1 summarises mean scores across domains, highlighting areas where SPs outperformed HFMs. Notable differences were observed, with the SP being particularly favoured for its realism (SP mean = 4.60, s.d. = 0.63), student self-confidence (SP mean = 4.18, s.d. = 0.97) and its ability to integrate theory and practice (SP mean = 4.43, s.d. = 0.84). In contrast, the HFMs scored slightly higher in clinical competence improvement (HFM mean = 4.87, s.d. = 0.52) and allowing learners to learn from their mistakes (HFM mean = 4.87, s.d. = 0.52).

It should be noted that a higher mean score for each scale or question indicates a higher level of agreement with it (Alconero-Camarero et al. 2016; Jiménez-Álvarez et al. 2024). The SSHF is divided into eight domains; however, the third domain was excluded because of the specific focus of this study (Table 2). As per the instructions from the survey developers, the questions were grouped to form these domains. The mean value for all SP domains was above or equal to four.

For the manikin, only ‘Increased self-confidence’ (3.98) and ‘Facilities and equipment’ (3.67) were below four, as seen in Table 2.

The analysis of responses to the open-ended questions yielded three recurring themes: nervousness, realism and improvement. Students noted that SPs heightened realism but also increased stress levels.

Participants in this study seemed to appreciate SP more, but they also mentioned that it added to their stress levels or nervousness during the simulation. This is seen in the following quotes:

Although students expressed heightened stress during SP scenarios, they acknowledged that this stress mirrored real clinical pressures. They appreciated the interactive nature of SPs and felt more ‘invested’ in patient outcomes:

Participants appreciated the opportunity to perform simulation scenarios using the SP modality because it helped them to improve their communication and other skills, as seen in the excerpt below:

Participants felt more exposed to the real environment when doing the simulation scenario using the SP modality:

Most participants mentioned that doing simulations with SPs was interesting and helpful because they could easily interact with the patients, and it was more realistic than doing simulations with manikins. However, some participants were stressed during the simulation because they were scared that they might do something wrong:

The last question in the questionnaire asked the students to identify which of the two modalities they preferred. Twelve participants chose SPs, and only three participants preferred HFMs.

The study utilised the SSHF, a previously validated tool that is widely used in healthcare simulation research (Alconero-Camarero et al. 2016). The instrument demonstrated internal consistency in earlier studies, with Cronbach’s alpha values consistently above 0.80, indicating high reliability. In this study, reliability was supported by consistent patterns of responses across domains, with narrow standard deviations in most items. This consistency suggests that the tool yielded stable results when used with this population of EMC students.

Validity in this study was addressed through both content and construct considerations:

Content validity: The SSHF questionnaire covers key domains relevant to SBE, including realism, self-confidence and integration of theory with practice. The minor adaptation (removal of Domain 3, communication or debriefing) was justified given the study’s design, which excluded team-based debriefing.

Construct validity: The findings aligned with existing literature, which indicates that SPs are perceived as more realistic and engaging, while HFMs are valued for procedural learning (Alsaad et al. 2017; Sterz et al. 2022). This congruence with prior research supports the instrument’s ability to capture relevant constructs.

External validity: Although the small sample size limits generalisability, the findings may be transferable to comparable educational settings in South Africa and other LMICs where decisions regarding simulation resources are particularly important.

The trustworthiness of the qualitative component was addressed using the criteria proposed by Lincoln and Guba (1985). Credibility was supported through the inclusion of direct participant quotations to illustrate and substantiate the identified themes. These quotations were used to ensure that the findings accurately reflected participants’ experiences and perspectives.

Dependability was enhanced by clearly documenting the qualitative analysis process, including the steps followed during manual coding and theme development. Confirmability was addressed by ensuring that themes were derived directly from participants’ responses rather than from preconceived assumptions. The analysis focused on patterns evident in the data, and qualitative findings were used to complement, rather than override, the quantitative results.

Transferability was supported through a detailed description of the study context, participant group and educational setting. Although the qualitative findings are not intended to be generalisable, sufficient contextual information is provided to allow readers to assess their relevance to similar educational environments. The use of a validated measurement tool alongside thematic analysis of qualitative responses strengthens the trustworthiness of the findings.

This study focused on student satisfaction regarding the use of SP and HFM modalities in pre-hospital emergency SBE scenarios at a single South African institution. As a pilot study with a small sample size, the findings are not intended to be generalisable. However, they provide preliminary insights that can inform the design and methodology of future, larger studies. The use of descriptive statistics without confidence intervals limits the precision of estimates and should be addressed in future studies with larger samples. This study also did not include formal debriefing in the scenarios completed by students. The authors acknowledge that debriefing is known to enhance reflection, learning consolidation and psychological safety in SBE. Its exclusion may have influenced students’ learning experiences and perceptions. Additionally, all participants completed the same scenario using both simulation modalities without randomisation of order. As a result, improvements in confidence may partly reflect familiarity with the scenario rather than differences between SPs and HFMs.

Findings suggest that incorporating SPs more systematically into EMC curricula may enhance realism, student confidence, and readiness for clinical practice. At the same time, HFMs remain indispensable for technical skill training. A blended approach, combining both modalities, may offer the most comprehensive educational benefits. Consideration of student stress and psychological safety is essential when introducing realistic simulation modalities, particularly in early training. These insights may assist educators in optimising simulation use within resource-limited curricula. For policymakers and curriculum designers, the study highlights that investment in SPs, though resource-intensive, is justified by student satisfaction and the development of critical interpersonal competencies. In resource-limited contexts, prioritising SP integration may yield greater educational returns than exclusive reliance on HFMs.

Further research is needed to determine the satisfaction of students concerning all SBE modalities at various institutions and health sciences departments. It would also be advisable to include all second-, third- and fourth-year students.